1 RADIANT POINT ACUPUNCTURE Northampton (413) E. Longmeadow (413) Please take a moment to provide us with information about your current and past health history. All information is considered privileged physician/patient communication and we will hold it in confidence as such. None of your history will be released with out your signed consent. NAME DATE AGE DOB SEX MARITAL STATUS ADDRESS HOME PHONE CELL/WORK ADDRESS OCCUPATION EMERGENCY CONTACT NAME OF PCP OR OBGYN MEDICAL INSURANCE CARRIER ARE YOU BEING TREATED ELSEWHERE? HOW DID YOU HEAR ABOUT OUR CLINIC?
2 MAJOR COMPLAINT/HEALTH PROBLEM YOU WOULD LIKE TO FOCUS ON: HOW DID THIS CONDITION DEVELOP & HOW LONG HAS IT PERSISTED? ANY SIGNIFICANT TRAUMA, SURGERIES OR INJURIES? FAMILY MEDICAL HISTORY: CURRENT MEDICATIONS (PRESCRIPTION, HERBAL & SUPPLEMENTARY):
3 NAME: DATE: HEALTH HISTORY please circle any symptoms you currently have or have had in the past 6 months GENERAL HEAD & NECK RESPIRATORY chills blurred vision asthma low energy heavy head hay fever dizziness headache persistent cough allergies phlegm in throat cough w/ blood fevers double vision shortness of breath excessive thirst eye pain/strain bronchitis insomnia nasal obstruction phlegm nervousness hearing loss difficult in/exhalation numbness ringing in ears sleep apnea spontaneous sweating sinus problems snoring night sweating hoarseness re-occurrent sore throat lack of sweating loss of sense of smell GASTROINTESTINAL weight loss sores on lips or tongue abdominal pain weight gain dental problems bloating, gas aversion to heat loss of sense of taste belching aversion to cold MUSCULOSKELETAL constipation CARDIOVASCULAR pain,weakness,numbness: loose stools chest pain neck & shoulders poor appetite palpitations arms & hands heartburn/acid reflux high/low blood pressure rib cage black stools poor circulation hips hemorrhoids swelling ankles knees & feet indigestion varicose veins low back nausea hypochondriac pain mid back vomiting anemia all over weakness NEUROLOGIC GENITOURINARY SKIN fainting urinary tract infection rashes convulsion blood in urine hives handwriting changes cloudy urine acne paralysis burning with urination psoriasis stroke scanty urine eczema tremor frequent urination dry skin vertigo urgency brittle nails DIET loss of control hair loss vegetarian EMOTIONAL LIFESTYLE vegan insomnia smoker eat meat /seafood often irritability, anxiety drink alcohol drink coffee/tea frequent anger/frustration recreational drug use crave sweets troubling dreams exercise regularly crave salt uncontrollable crying exercise excessively often eat fast food depression often eat dairy grief forgetful often eat fried foods
4 NAME: DATE: Age at which menses began Date of last menstruation How many days from one period until the next? Is this regular from month to month? How many days do you bleed? How heavily? What color is the blood? Is there clotting? Do you spot or bleed between periods? Do your bowel movements become loose prior to your period? Do you have premenstrual tension? Do you have premenstrual breast tenderness? Are your periods painful? How many days does the pain last? Do you have low back pain with your menses? Do you have skin break outs at certain times of your cycle? Do you douche or use vaginal lubricants? Do you feel you are experiencing peri-menopause? Are using a birth control method? How many pregnancies have you had? How many children do you have? How many abortions have you had? How many miscarriages have you had? How many times has a D&C been performed? NUMBER YEAR PLEASE CIRCLE & DATE ANY SYNDROMES YOU HAVE/HAD Abnormal Pap Abnormal vaginal discharge Cirrhosis Venereal disease Pelvic Inflammatory Disease Heart disease Chlamydia Fibroids Thyroid disorder Endometriosis Polyps Hepatitis Yeast infections Pelvic adhesions Arthritis Genital sores Pelvic abnormalities UTI Breast infections or lumps Autoimmune disease Blood disorders Diabetes PCOS Stroke history Epilespy Mental illness Cancer
5 *FERTILITY & PREGNANCY PATIENTS PLEASE CONTINUE TO RELEVANT PAGES CONSENT FOR ACUPUNCTURE TREATMENT I hereby request and consent to acupuncture treatments and other procedures within the scope of the practice of acupuncture on me by the acupuncturist named below. I understand that methods of treatment may include, but are not limited to, acupuncture, acupressure, moxa, massage, cupping, electrical stimulation, Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. I will immediately notify my acupuncturist of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that It may have some side effects including bruising and/or numbness or tingling near the needling sites that may last a few days. There have been rare instances reported in which a patient fainted, developed a scar or infections, experienced a spontaneous miscarriage, sustained a pneumothorax (air in the chest cavity that could cause a collapsed lung) or a burn from moxa or cupping. The herbs and nutritional supplements that have been recommended are considered safe in the practice of Chinese medicine. Some herbs may have undesirable effects in larger doses than we recommend. Some possible side effects of taking herbs are nausea, gas, stomachache, diarrhea or rashes. I will notify my acupuncturist if I am pregnant since some herbs can be harmful. I do not expect my acupuncturist to be able to anticipate and explain all possible risks and complications of treatments, and I wish to rely on my acupuncturist to exercise good judgment during the course of treatment. I understand that results are not guaranteed. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition (s) for which I seek treatment. Patient Signature: Date: Acupuncturist Signature: Date: FINANCIAL AGREEMENT Your appointment time is reserved specifically for you. Therefore, Radiant Point Acupuncture requests at least 24 hours notice for any cancellation or rescheduling of appointment times.cancellation with less then 24 hours notice will result in the full charge of the scheduled treatment to your account. Obvious exceptions will be made for emergencies. Patient Signature: Date: Credit card number & expiration date to hold all appointments:
6 *FERTILITY PATIENTS NAME: DATE: How long have you been trying to conceive? Are you seeing a Reproductive Endocrinologist? Have you been given a specific western medical diagnosis in regards to infertility? Do you ovulate on your own? On what cycle day? Have you taken any medications to help you ovulate? Do you know your day 3 FSH level? Prolactin level? Please list any other lab tests performed and the results: Have you used a BBT graph to chart your body temperature? Have you had an HSG exam? Results How is your sexual energy? Emotional energy? Describe any family gynecological history that may be relevant? Are you using any lubricants or douches on a regular basis? Did your mother take DES when pregnant? Do you have any autoimmune diseases? Are you seeing any alternative health care practitioners? What forms of ART are you or have you tried? please list procedure, medications & date Has your partner had any lab tests performed? please list date and results
7 *PREGNANCY PATIENTS NAME: DATE: What is your estimated due date? Where your cycles regular prior to conception? What is your primary health concern? How many days long? Is this your first pregnancy? labor and deliveries including dates: If no, please describe your previous pregnancy, Who is your OBGYN? Do you have a Midwife? Where are you planning on delivering? Please briefly describe your diet: What is your exercise routine? How are you feeling emotionally? Have you had any major surgeries or hospitalizations? Please list all medications: please include all prescriptions, herbs, supplements and over the counter aids: Please circle any conditions that are applicable now or have been in the past Cardiovascular disease Hypertension Anemia Allergies Depression Diabetes